BULLETIN NO - Government of New Jersey



BULLETIN NO. 07-17

TO: ALL NEW JERSEY HEALTH INSURANCE COMPANIES; HOSPITAL SERVICE CORPORATIONS; MEDICAL SERVICE CORPORATIONS; HEALTH SERVICE CORPORATIONS; HEALTH MAINTENANCE ORGANIZATIONS; DENTAL SERVICE CORPORATIONS; DENTAL PLAN ORGANIZATIONS; PREPAID PRESCRIPTION SERVICE ORGANIZATIONS; ORGANIZED DELIVERY SYSTEMS; AND OTHER INTERESTED PARTIES

FROM: STEVEN M. GOLDMAN, COMMISSIONER

RE: AMENDMENTS TO THE HINT FORMS

On March 26, 2007 the Department issued Bulletin No. 07-07, which addressed amendments to the HINT Enrollment Forms, Exhibits 1A and 1B of the Appendix to N.J.A.C. 11:22-3 (Electronic Transmission and Receipt of Health Care Claims - “HINT” Enrollment forms”). It has come to the Department’s attention that the forms in Exhibits 1A and 1B as attached to Bulletin 07-07 do not include the “LOC #s” under the “Activity” section for the “Primary,” “OB/GYN” or “Dentist” entries. Therefore the Department is providing as attachments hereto the corrected form pages that now include spaces for the entry of the “LOC #” information. These forms can be accessed via the Department’s website at: . The Department intends to propose amendments to Exhibits 1A and 1B of N.J.A.C. 11:22-3 to codify the revised forms in the near future.

8/29/07 /s/ Steven M. Goldman

Date Steven M. Goldman

Commissioner

DHT07-06/inoord

|B. [Employee] Information – to be completed |Name (Last, First, MI): |SSN: |

|by the [Employee] | | |

|Home | |Birthdate (mm/dd/yyyy): | Male |

| |Street/Apt:________________________________________________________________________________________ | |Female |

| |Street/Apt:________________________________________________________________________________________ | | |

| |City:___________________________________________________ State:_____ Zip Code: _____________________ | | |

| | |Phone: (_____)________________ |

| | |[Email: _______________________________] |

|Work | | |

| |[Employer] Name:__________________________________________________________________________________ |Phone: (_____)__________________ |

| |Address:__________________________________________________________________________________________ |[Email: _________________________________] |

| |City:___________________________________________________ State:_____ Zip Code: ______________________ |Employment Date: _____/_____/_____ |

| | |Hours worked per week:_________ |

|Activi| Add Remove Continuation Other Change If a name change, indicate prior name: |

|ty | |

| |[Primary LOC #:] _______________________________________________________ |[NPI #:] |[Current Patient: Yes |

| |address: zip+4 | |No] |

| |] | | |

| |[Ob/Gyn LOC #:] _______________________________________________________ |[NPI #:] |[Current Patient: Yes |

| |address: zip+4 | |No] |

| |] | | |

| |[Dentist LOC #:] _______________________________________________________ |[NPI #:] |[Current Patient: Yes |

| |address: zip+4 | |No] |

| |] | | |

|Other Health Coverage? Yes No If yes: |[Other Rx Coverage? Yes No If yes: |

|Payer Name: ____________________________________________________________ |Payer Name: ____________________________________________________________ |

|Policy #: ________________________________________ |Policy #: ___________________________________________ |

|Medicare ID#, if any: |Medicare ID#, if any: ] |

|Previous Coverage? Yes No |Payer Name:____________________________________________________________ |

|If Yes: |Policy #:____________________________ |

|Effective date: _____/_____/_____ Termination date: _____/_____/_____ |[Submit a Certificate of Creditable Coverage] |

|C. Plan Option – to be completed by the [Employee] Check one [Plan Name] [and] [Copay] [and] [or] [Deductible] [and] [or] [Coverage Status] |

|D. Other Individuals Covered – to be completed by the [Employee] Identify individuals other than yourself for whom you are adding/changing/removing/continuing coverage. Attach additional pages if necessary, with |

|your signature and dated. [Attach proof if full-time post-secondary student.] [Attach proof of disability.] |

|1. Spouse; Domestic or Civil Union Partner |2.Child |3. Child |4. Child |

|Add Remove | Add Remove | Add Remove | Add Remove |

|Other Continue Spouse |Other Continue |Other Continue |Other Continue |

|Continue CU Partner (NJSGC) | | | |

NONGROUP ENROLLMENT/CHANGE REQUEST

|[Carrier Logo] |

|[Carrier Name] |

|A. Type of Activity – to be completed by [Applicant] Refer to instructions [on back] before completing this form. Print clearly. |

|Activity – Check all that apply |Effective Date/ |Reason |

| |Date of Event | |

|ADD | Enrollment of a new [Insured/Enrollee/Subscriber] |_____/_____/_____ |________________________________________________________ |

| |Add Spouse[/Civil Union Partner] |_____/_____/_____ |________________________________________________________ |

| |[ Add Civil Union Partner] |[_____/_____/_____] |[_______________________________________________________] |

| |Add Domestic Partner |_____/_____/_____ |________________________________________________________ |

| |Add Dependent Child |_____/_____/_____ |________________________________________________________ |

| REMOVE | Remove [Insured/Enrollee/Subscriber] |_____/_____/_____ |________________________________________________________ |

| |Remove Spouse[/Civil Union Partner] |_____/_____/_____ |________________________________________________________ |

| |[ Remove Civil Union Partner] |[_____/_____/____] |[_______________________________________________________] |

| |Remove Domestic Partner |_____/_____/_____ |________________________________________________________ |

| |Remove Dependent Child |_____/_____/_____ |________________________________________________________ |

| OTHER | Name Change |_____/_____/_____ |_______________________________________________ |

|CHANGE |Change Plan |_____/_____/_____ |________________________________________________________ |

| |Other |_____/_____/_____ |________________________________________________________ |

| |[Add/Change Office ID Numbers: Primary/OB/Gyn] |_____/_____/_____ |________________________________________________________ |

|B. [Applicant] Information |Name (Last, First, MI): |

|SSN: |Birthdate (mm/dd/yyyy) | Male |[Email:] |

| | |Female | |

|Are you a resident of New Jersey? Yes No |Do you maintain a home in any other state? Yes No If yes: |

| |Name of State:______________________________ Number of months you live there each year: _________ |

|Address |Primary Residence: |Other Residence: |

|Informati|Street/Apt:___________________________________________________________ |Street/Apt:___________________________________________________________ |

|on |Street/Apt:___________________________________________________________ |Street/Apt:___________________________________________________________ |

| |City:___________________________________________________ State:______ Zip Code: _____________________|City:___________________________________________________ State:______ Zip Code: _____________________|

| |Phone: (_____)_________________ |Phone: (_____)_________________ |

| |Your billing address: Primary residence Other residence P.O. Box or Other (specify): |

|Activity | Add Remove Other Change Continue If a name change, indicate prior name: |

| |[Primary LOC#:] ______________________________________________________ |[NPI #:] |[Current Patient: Yes |

| |address: zip+4 | |No] |

| |] | | |

| |[Ob/Gyn LOC#:) _____________________________________________________ |[NPI #:] |[Current Patient: Yes |

| |address:] zip+4 | |No] |

-----------------------

| | |[pic] | | |

| | |State of New Jersey | | |

| | |Department of Banking and Insurance | | |

| | |Legislative and Regulatory Affairs | | |

|Jon S. Corzine | |PO Box 325 | |Steven M. Goldman |

| | |Trenton, NJ 08625-0325 | | |

| | | | | |

|Governor | |Tel (609) 984-3602 | |Commissioner |

| | |Fax (609) 292-0896 | | |

Visit us on the Web at

New Jersey is an Equal Opportunity Employer • Printed on Recycled Paper and Recyclable

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